The right mix: why workforce planning and rostering has an impact on quality of care

Nursing skill mix is a recognised predictor of health care quality. Sufficient numbers of nurses with the right skills and experience is fundamental to effective and safe care delivery (RCN 2010).

Maintenance of adequate skill mix is an intricate combination of the correct estimation of a nursing establishment and the skilled deployment and utilisation of that establishment.  This includes the allocation and management of both planned and unplanned leave.

Rostering is a key element of effective workforce planning, and one of the key roles of the senior charge nurse. It is critical to quality yet traditionally has not been included in educational programmes. Instead it is a skill that tends to develop as post holders progress in their managerial role.

The challenge to identify the optimum level and mix of nursing staff, and manage an effective duty roster is one that is faced by NHS managers on a daily basis (Ball & Cotton 2011).

With the implementation of Agenda for Change and family-friendly policies in the UK NHS providers have experienced an increase in the entitlement of planned and unplanned leave particularly within the nursing and midwifery workforce.

Within Scottish NHS health boards have an additional 22.5 per cent included in the nursing establishment (referred to as time out) to allow for predicted absence (Nursing and Midwifery Workload and Workforce Planning Project (NMWWP) for Scotland, Flynn et al 2010). This breaks down to 15 per cent of total whole time equivalent (WTE) for annual leave; 4 per cent for sick leave; 2 per cent for study leave; 1 per cent for maternity leave and 0.5 per cent for other planned leave (e.g. carer’s leave).

The predominantly female workforce within nursing and midwifery presents unique challenges in the allocation of planned leave. With almost 70 per cent of nurses being above 40 years old staff tend to request planned leave during school holiday periods and those who find themselves as carers of children and/or  elderly relatives increasingly request additional unplanned leave.

These increased pressures require the nursing resource to be managed effectively. An over-allocation of leave can lead to over reliance on the use of supplementary staffing (Simpson 2010) and thus avoidable, additional cost pressures. Operation of departments with minimum or mandated safe staffing levels (RCN 2010) or supplementary staffing can also introduce unnecessary risk. The requirement to absorb any unplanned leave during such times has the potential to increase such risks further.

Chart 1 (attached right) shows a trend in planned leave allocation plotted against target planned leave hours per week within an A&E department prior to their efforts to reduce variance. High volume of annual leave hours correlated to peak school holiday times (June –August and weeks 1 and 2 in October).

Allocation of planned leave to best suit staffs’ personal circumstances can arguably be viewed as an effective retention strategy but as noted above can have significant negative impact on the quality and cost of care.

Existing approaches to allocating planned leave and rostering differ and range from self rostering, first requests honoured approaches to more structured approaches where target hours of leave allocation per week are set. Regardless of the approach agreed in an area, managers have often struggled to implement and sustain fair and equitable systems that maximise available skill mix.

In addition most staff are unaware of the challenges associated with allocating all planned leave equally across the year and failure of managers to honour planned leave requests can lead to staff discontent, poor team/individual behaviors and thus potentially negatively impact on the culture of care.

The following provides a case study of how one Accident and Emergency department improved their management of leave.

A national review of the SCN role – Leading Better Care (Scottish Government (2008) highlighted the need for SCNs to be provided with opportunities to enhance their skills and knowledge in order that they can effectively deliver on their role. The author attended a locally provided LBC educational programme. After taking part in manpower planning and staff deployment workshops she recognised the need to more effectively manage her departmental planned leave.

One key issue for the author was the lack of shared team ownership for the management of planned leave. Traditionally decisions to honour (or not) planned leave requests had been the prerogative of the SCN. She therefore worked with the whole nursing team to highlight the challenges faced when trying to allocate planned leave.

In the first instance she calculated all planned leave allowances and mapped previous planned leave hours against the target hours needed to be allocated per week to remain within the national 15 per cent allocation (see chart 1) and shared this with staff. Staff were shocked at the volume of planned leave and immediately recognised the need for planned leave to be taken throughout the year.

Discussions over the impact of peaks of planned leave allocation on the staffing levels within the department led the team to agree to change the way in which planned leave was managed. They tested an approach where all staff provisionally requested their planned leave for the summer holiday period by email to the SCN. She then charted the requested hours per week and presented the anonymised data to the team at their regular departmental meeting.

The purpose of this was to avoid previous first come first served approaches and the potential for previous disputes over last years planned leave to influence individual’s willingness to take collective responsibility to keep planned leave hours to 15 per cent.

As a result of sharing the data, team members could clearly see the weeks where too many hours had been provisionally requested and because they were all unaware of who had requested these weeks individuals readily volunteered to reduce the variance by changing their weeks where necessary.

The simple process, while time consuming to establish, ensured collective ownership for the maintenance of safe staffing levels. As a result the department managed to significantly reduce the variance in planned leave allocation (see chart 2 attached right) and agreed to spread this approach across the whole year.

This case study highlights the significant role nurse managers play in the deployment of staff and the need for robust education and development of approaches to this aspect of their role. Managers who can develop a sense of collective responsibility within a team for safe and effective care can work creatively with staff to achieve this.

The simple process has anonymity and data sharing at its core and we believe that these increased staff awareness of the impact of variance in planned leave allocation were and thus supported the development of collective ownership for the maintenance of safe staffing levels.

The initiative to share the responsibility for maintaining safe staffing levels has had a positive effect on staff with staff now demonstrating an understanding of and ownership of the need to maintain safe staffing levels.

The effects ofconsistent skill mix on the day to day management of the department have had other positive effects. Staff now report that they have managed fluctuations in patient activity and acuity more easily than previous years.

While improved patient outcomes cannot be determined from this one case study such an approach to planned leave allocation has not only optimised skill mix availability but also ensured all staff have regular rests from work – a recognised employer requirement (The Working Time Regulations 1998). Both outcomes are recognised as crucial to ensuring safe, effective and efficient patient care.

Mary Cumming is senior charge nurse in the accident and emergency department at NHS Tayside. Deborah Baldie is senior nurse- practice development at NHS Tayside and clinical research fellow, Social Dimensions of Health Institute, Universities of Dundee and St Andrews, Kevin Hurst is head of nursing and midwifery education and workforce planning and development atNHS Tayside, Janice Rattray is a reader at the School of Nursing and Midwifery, University of Dundee

References

Ball, J., Cotton, H., 2011. Make sure nurse numbers add up. Health Service Journal, 12^th May 2011, 20-22

Flynn, B., Kellagher, M., Simpson, J., 2010. Workload and workforce planning: tools, education and training. Nursing Management, 16, 10, 32-35

Royal College of Nursing, 2010. Guidance on safe nurse staffing levels in the UK, London: RCN

Scottish Government, 2008. Leading Better Care: Report of the Senior Charge Nurse Review and Clinical Quality Indicators Project

Simpson, J., 2010. Workload and workforce planning: supplementary staffing. Nursing Management, 17, 2, 24-28

The Working Time Regulations, 1998. SI 1998/1833. London, HMSO